Fortification of food needs to be updated

How do you protect a population from a disease that requires only a simple daily supplement to eradicate it? Do you pass out vitamins? How can you make sure people are taking them? In the US and most other countries, this is done in a process called fortification, adding essential vitamins and minerals to foods with wide cultural acceptance.

For example, folic acid, a type of B vitamin, protects against neural tube defects (NTDs), which are sometimes fatal disorders in development of the brain, spinal cord, and spine of a fetus. The catch is that, to get the protective benefits of folic acid, it needs to be consumed before and during pregnancy.

Some foods, including spinach and broccoli, contain trace amounts of folic acid, but not enough to reach the recommended dosage. The other difficulty is that half of all American pregnancies are unplanned--so how to know when to take folic acid supplements? After much debate, which included the questionable phrase "all women are pregnant unless proven otherwise," the FDA mandated in 1998 that all enriched grain products be also fortified with folic acid as well.

Flour wasn't the first or only thing to be fortified: iodine was added to salt in the 1920s and, in the 1930s, vitamin D was added to milk. The increase in iodine intake by the U.S. population virtually eliminated goiter within the country's borders, and vitamin D did the same to rickets. For a great history on fortification, check out this article by David Bishai and Ritu Nalubola.

Since WWII, however, supplements such as iron and various B vitamins have almost exclusively been added to wheat flour and cereal grain. Why? It's all based on an edict from the War Food Administration in 1943:

"For years, wheat has contributed at least one-fourth of the calories to the average American diet. White flour constitutes 95 percent of the milled wheat products in this diet; and yet, by nature of its refining process, from 80 to 90 percent of the micro-nutrients (thiamin, niacin, and iron) are lost. The American people prefer white bread, and the changing of food habits in a democratic system of government is difficult."

From what I could gather, the "one-fourth" number is based on two surveys conducted in 1935-1936 and compiled in 1941 by the U.S. Department of Agriculture. Although they mostly focused on nuclear, white families around the country, these surveys provided a scientific rationalization for the fortification of wheat flour. Apparently, the War Food Administration was worried that Americans were a less-capable fighting force because of their diet:

"The Russian Army is fed whole grain. It has been the most able army in combat with the whole grain-eating Nazis."

In the patriotic spirit of the time, the grain industry wholeheartedly undertook its part for the war effort. And after the war, the enrichment and fortification of grains had become the new normal.

Fast-forward to the present: the 1998 mandatory addition of folic acid to fortified grains has dropped the incidence of NTDs by 36% in the U.S., which is wonderful.

But, the dietary landscape of America has greatly diversified since those 1930s surveys that cemented grains as an American staple. On the contrary, likely a quarter of the Americans don't eat enriched grains, thereby missing out on the health benefits. In an increasingly health-conscious country, sugary breakfast cereal sales are down by ten percent in the last decade. Ironically, these same people who are cutting out sugar-ladened, glutinous food may inadvertently be hurting their health in another way.

Considering shifting food culture, perhaps a different way of distributing these supplements is by incorporating them directly into the biology of the foodstuffs itself. For example, there is an effort in the Philippines aimed at genetically modifying rice so that it could produce vitamin A, thereby alleviating a blindness-causing deficiency in millions of the poorest Filipinos:

However we do it, it’s time to figure out how else we could get these essential vitamins and minerals to the public. And nowadays there isn't a global Nazi threat to muddle the issue.

Next time, we’ll learn more about how the gluten-free diet fits into this fortification discussion.



Banner image credit: Library of Congress.